This provider/recipient webinar covers the process of transitioning into the Managed Medical Assistance program and what services are available to assist recipients during the transition period.
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Transitioning to Managed Medical Assistance (MMA)
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7. • Preserve continuity of care, and to greatest extent
possible:
– Recipients keep primary care provider
– Recipients keep current prescriptions
– Ongoing course of treatment will go uninterrupted
• Plans must have sufficient and accurate provider
networks under contract and taking patients.
– Allows an informed choice of providers for
recipients and the ability to make appointments.
8. • Plans must have the ability to pay providers fully
and promptly to ensure no provider cash flow or
payroll issues.
• Choice Counseling call center and website must
be able to handle volume of recipients engaged
in plan choice at any one time.
– Regional roll out to ensure success
10. • Choice counseling is a service offered by
the Agency for Health Care Administration
(AHCA), through a contracted enrollment
broker, to assist recipients in
understanding:
– managed care
– available plan choices and plan
differences
– the enrollment and plan change process.
• Counseling is unbiased and objective.
11. • The Choice Counseling process can be
triggered by one of many factors:
─A recipient is determined to be newly eligible
for managed care and is mandatorily required
to or may voluntarily choose a managed care
plan
─A current plan enrollee desires to change from
one plan to another plan.
12. Recipient determined
eligible for enrollment
or enters open
enrollment
Recipient receives
communication
informing him of
choices
Recipient may enroll
or change via phone,
online or in person
Enrollment or change
is processed during
monthly processing
and becomes effective
the following month
Newly eligible
recipients are allowed
90 days to “try” the
plan out, before
becoming locked-in
13. How Do Recipients Choose an MMA Plan?
• Recipients may enroll in an MMA plan or change plans:
– Online at :www.flmedicaidmanagedcare.com
Or
– By calling 1-877-711-3662 (toll free) and
• speaking with a choice counselor
OR
• using the Interactive Voice Response system (IVR)
• Choice counselors are available to assist recipients in selecting a
plan that best meets their needs.
• This assistance will be provided by phone, however recipients with
special needs can request a face-to-face meeting.
14. When Can Recipients Change Plans?
• Recipient who are required to enroll in
MMA plans will have 90 days after joining
a plan to choose a different plan in their
region.
• After 90 days, recipients will be locked in
and cannot change plans without a state
approved good cause reason or until their
annual open enrollment.
15. • Welcome Letter:
─ Approximately 60 days prior to the plan begin
date, recipients will receive a letter and a packet
of information detailing their choice of plans and
how to choose a plan.
• Letter
• Brochure that provides plan information
specific to the recipient’s region
• Information on how to make a plan choice
• The plan to which they’ll be assigned if they
don’t make a choice
16. • Reminder Letter: Reminds fully eligible recipients of
their need to make an enrollment choice by a specific
cut-off date, (this information was also included in the
original letter).
• Confirmation Letter: Mailed after a voluntary plan
choice or change to confirm the recipient’s selection
and to inform of next steps and rights.
• Open Enrollment: Mailed 60 days prior to the
recipient’s plan enrollment anniversary date to remind
them of the right to change plans.
18. Region Counties
1 Escambia, Okaloosa, Santa Rosa, and Walton
2
Bay, Calhoun, Franklin, Gadsden, Gulf, Holmes, Jackson, Jefferson, Leon,
Liberty, Madison, Taylor, Wakulla, and Washington
3
Alachua, Bradford, Citrus, Columbia, Dixie, Gilchrist, Hamilton, Hernando,
Lafayette, Lake, Levy, Marion, Putnam, Sumter, Suwannee, and Union
4 Baker, Clay, Duval, Flagler, Nassau, St. Johns, and Volusia
5 Pasco and Pinellas
6 Hardee, Highlands, Hillsborough, Manatee, and Polk
7 Brevard, Orange, Osceola, and Seminole
8 Charlotte, Collier, DeSoto, Glades, Hendry, Lee, and Sarasota
9 Indian River, Martin, Okeechobee, Palm Beach, and St. Lucie
10 Broward
11 Miami-Dade and Monroe
19. Region
Pre-Welcome
Letter
Welcome
Letter
Reminder
Letter
Last Day to
Choose a Plan
Before Initial
Enrollment
Date Enrolled
in MMA Plans
1 4/1/2014 5/26/2014 6/23/2014 7/17/2014 8/1/2014
2 1/2/2014 2/17/2014 3/24/2014 4/17/2014 5/1/2014
3 1/1/2014 2/17/2014 3/24/2014 4/17/2014 5/1/2014
4 1/2/2014 2/17/2014 3/24/2014 4/17/2014 5/1/2014
5 2/3/2014 3/24/2014 4/21/2014 5/22/2014 6/1/2014
6 2/3/2014 3/24/2014 4/21/2014 5/22/2014 6/1/2014
7 4/1/2014 5/26/2014 6/23/2014 7/17/2014 8/1/2014
8 2/3/2014 3/24/2014 4/21/2014 5/22/2014 6/1/2014
9 4/1/2014 5/26/2014 6/23/2014 7/17/2014 8/1/2014
10 3/3/2014 4/21/2014 5/26/2014 6/19/2014 7/1/2014
11 3/3/2014 4/21/2014 5/26/2014 6/19/2014 7/1/2014
25. If a Recipient does
not Make a Plan
Choice, how will the
Agency determine
which MMA plan
recipients will be
auto assigned to?
• For Recipients who are required to enroll
in an MMA plan:
– Recipient is identified as eligible for a
specialty plan.
– The recipients prior Medicaid managed
care plan is also an MMA plan.
– Recipient is already enrolled (or has
asked to be enrolled) in a long term care
plan with a sister MMA plan.
– The recipient has a family member(s)
already enrolled in, or with a pending
enrollment, in an MMA plan.
26. Specialty Plans
Can recipients choose to be in or identify themselves
as eligible for a specialty plan?
• Yes, recipients can inform their choice counselor during
their choice period that they would like to enroll in a
specialty plan if they believe they are eligible for a
specialty plan available in their region.
• The specialty plan will be responsible for confirming that
the recipient meets the eligibility criteria for the plan.
27. Child Welfare specialty plan
Children’s Medical Services
HIV/AIDS
Serious Mental Illness
If a recipient qualifies for enrollment in more than one of the available specialty plan
types, and does not make a voluntary plan choice, they will be assigned to the plan for
which they qualify that appears highest in the chart below:
Freedom Health specialty plans
28. Medicaid is mailing important information to you
regarding the MMA program to your home. Make sure
we have your current address!
To check,
• Please call the ACCESS Customer Call Center
(866) 762-2237
OR
• Visit http://www.myflorida.com/accessflorida/
30. • MMA plans are responsible for the coordination of care for new
enrollees transitioning into the plan
• MMA plans are required to cover any ongoing course of treatment (services
that were previously authorized or prescheduled prior to the enrollee’s
enrollment in the plan) with the recipient’s provider during the 60 day
continuity of care period, even if that provider is not enrolled in the plan’s
network.
•
– The following services may extend beyond the continuity of care period
and as such, the MMA plans are responsible for continuing the entire
course of treatment with the recipient’s current provider:
• Prenatal and postpartum care (until six weeks after birth)
• Transplant services (through the first year post-transplant)
• Radiation and/or chemotherapy services (for the current round of
treatment).
31. If the services were prearranged prior to enrollment with the plan, written
documentation includes the following:
• Prior existing orders;
• Provider appointments, e.g., dental appointments, surgeries, etc.;
• Prescriptions (including prescriptions at non-participating pharmacies); and
• Behavioral health services.
• MMA plans cannot require additional authorization for any ongoing course of
treatment. If a provider contacts the plan to obtain prior authorization during the
continuity of care period, the MMA plan cannot delay service authorization if
written documentation is not available in a timely manner. The plan must approve
the service.
• However, the MMA plan may require the submission of written document (as
described above) before paying the claim.
32. Providers should keep previously
scheduled appointments with
recipients during transition
33. • Service providers should continue providing services
to MMA enrollees during the 60-day continuity of
care period for any services that were previously
authorized or prescheduled prior to the MMA
implementation, regardless of whether the provider is
participating in the plan’s network.
• Providers should notify the enrollee’s MMA plan as
soon as possible of any prior authorized ongoing
course of treatment (existing orders, prescriptions,
etc.) or prescheduled appointments.
35. Continuity of Care During Transition
Provider Reimbursement
• MMA plans are responsible for the costs of continuing any ongoing course
of treatment without regard to whether such services are being provided by
participating or non-participating providers.
• The MMA plan must pay non-participating providers at the rate they
received for services rendered to the enrollee immediately prior to the
enrollee transitioning for a minimum of thirty (30) days, unless the provider
agrees to an alternative rate. Providers will need to follow the process
established by the managed care plans for getting these claims paid
appropriately.
• Providers may be required to submit written documentation (as described
above) of any prior authorized ongoing care, along with their claim(s) in
order to receive payment from the plan.
36. Continuity of Care During Transition
• Do the managed care plans have to honor prior authorizations that were issued (either
through one of the Agency’s contracted vendors or a managed care plan) prior to the
recipient’s enrollment in the MMA plan? Examples include:
– Home health
– Dental
– Behavioral Health
– Durable medical equipment (rent-to-purchase equipment, ongoing rentals, etc.)
– Prescribed drugs
• Yes. During the continuity of care period, the MMA plan must continue to pay for
any prior approved services, regardless of whether the provider is in the plan’s
network. During this timeframe, the plan should be working with the enrollee and
their treating practitioner to obtain any information needed to continue
authorization after the continuity of care period (if the service is still medically
necessary). After the continuity of care period, if the provider is not a part of the
plan’s network, the enrollee may be required to switch to a participating provider.
37. Continuity of Care During Transition
Pharmacy
• For the first year of operation, MMA plans are required to use the Medicaid Preferred
Drug List (PDL) in order to ensure an effective transition of enrollees during
implementation.
• For the first 60 days after implementation in a region, MMA plans or Pharmacy Benefit
Managers (PBMs) are required to operate open pharmacy networks so that enrollees may
continue to receive their prescriptions through their current pharmacy providers until
their prescriptions are transferred to in-network providers. MMA plans and/or PBMs
must reimburse non-participating providers at established open network reimbursement
rates.
• For new plan enrollees (i.e., enrolled after the implementation), MMA plans must meet
continuity of care requirements for prescription drug benefits, but are not required to do
so through an open pharmacy network.
• During the continuity of care period MMA plans are required to educate new enrollees
on how to access their prescription drug benefits through their MMA plan provider
network.
38. Continuity of Care During Transition
Pregnancy
• If a pregnant Medicaid recipient enrolls in an MMA plan and
her OB/GYN is not a part of the plan’s network does the plan
have to continue to pay for the services?
• Yes. The MMA plan must continue to pay for services
provided by her current provider for the entire course of her
pregnancy including the completion of her postpartum care
(six weeks after birth), regardless of whether the provider is in
the plan’s network.
39. • If you have a complaint about Medicaid
Managed Care services, please complete
the online form found at:
http://apps.ahca.myflorida.com/smmc_cirts/
• If you need assistance completing this
form or wish to verbally report your
issue, please contact your local Medicaid
area office.
• Find contact information for the
Medicaid area offices at:
http://www.mymedicaid-florida.com/
http://apps.ahca.myflorida.com/smmc_cirts/
40. Questions can be emailed to:
FLMedicaidManagedCare@ahca.
myflorida.com
Updates about the Statewide
Medicaid Managed Care program
are posted at:
www.ahca.myflorida.com/SMMC
Upcoming events and news can be found
on the “News and Events” tab.
You may sign up for our mailing list by
clicking the red “Program Updates” box
on the right hand side of the page.
Much of the early success of the LTC program relies on recipients, whether in the home or the community, continuing to get the services they need without interruption. There are important roles for both providers and for plans to ensure this critical continuity of care occurs.When the LTC program rolls out in a region, (read bullet #1 and #2)